4. 1 and 3
Myocardial infarction is a leading differential diagnostic consideration for the presentation of this patient, and electrocardiography is an important first step in the assessment of this possible condition. Chest radiography is also an important first step in the evaluation of this patient because community-acquired pneumonia is also a leading consideration for this patient’s presentation. Furthermore, when myocardial infarction is a possibility, another leading cause of acute chest pain- aortic dissection- must also be considered and excluded, and chest radiography is often used to assess for the widened mediastinum that may herald the presence of this disorder.
Echocardiography is not an unreasonable test to obtain for this patient, particularly given the possibility of pericarditis as a cause of the patient’s presenting complaint of chest pain, but it may be more rewarding to obtain the electrocardiogram first and then base the next steps on the result of the electrocardiogram and chest radiographic results before proceeding to echocardiography, particularly given that no clinical evidence of heart failure was noted.
The patient’s electrocardiogram showed mild tachycardia with an otherwise normal rhythm. The patient’s first troponin level was normal. Frontal chest radiography was performed (Figure 1).
Figure 1. Frontal chest radiography.
Which of the following represents the most accurate assessment of the chest radiographic findings? (Click on the correct answer to proceed to the fourth of nine pages)